Solving Diabetes in South Texas
By Joey Gomez
Rosario Contreras doesn’t know why she has diabetes.
After being diagnosed more than three years ago, Contreras, 50, says she is confused about how she contracted the disease, because she has no family history and stays relatively fit for her age.
As an immigrant who first moved to the region with her children 14 years ago, Contreras originally thought that working hard cleaning houses and tending lawns would be enough to counter the habits she noticed from people in the United States.
It prompted her to eat at home as much as she could, and on days when she was on the job, she would take her own cooked meals with her. Because of these efforts, Contreras doesn’t know why she has the disease and thinks she contracted it after a big scare following an accident more than three years ago.
None of her other family members has the disease, and she says she avoids fast food and comida chatarra (junk food). She eats food she makes at home, and swears off candy for her and her children. In her opinion, Contreras says while she uses only the smallest amounts of salt and sugar in the foods she makes, she believes food here in the U.S. contains chemicals that promote the disease.
Doctors are not convinced that is possible. Yet cases like Contreras point out how a lack of health education among the poorest in the Rio Grande Valley only adds to a growing problem.
“I don’t know why I have diabetes. I take care of myself,” Contreras said in Spanish. “In Mexico, everything is home cooked. Here, everything is bought. We would rather buy our food here. That’s why people are obese. We all want everything quickly.”
Contreras says she hasn’t seen a doctor lately because she can’t afford the visits. She last visited Nuestra Clinica del Valle in San Juan over a year ago, and says the $40 a day she gets cleaning houses is not enough usually to cover the initial visit, tests, and medications she needs to manage the disease, so she tries to make up for it through hard work.
“I have no complications, and I’m doing preventive (measures),” Contreras says. “Doctors need to be more considerate. Those clinics that work for the government and who supposedly work for low-income people are not telling the truth. I can’t do everything they ask me to,” Contreras says.
Diabetic until proven otherwise
The harsh reality of diabetes in the Rio Grande Valley is that every patient has the disease until proven otherwise. That’s the outlook, according to Dr. Marcel Twahirwa, an endocrinologist and director of Joslin Diabetes Center who, along with staff and partners at Doctors Hospital at Renaissance, find themselves on the front lines combatting a near pandemic disease that affects Latinos here more than any other part of the country.
The numbers in the region indicate a very serious problem. Almost 11 percent of the 1.2 million people in South Texas have the disease, which totals to nearly 120,000 overall, according to the National Minority Quality Forum, a research organization dedicated to ensuring that “high-risk racial and ethnic populations and communities receive optimal health care,” for the disease.
“Here in the Valley, we know the area is very rich in diabetes. Probably about 30 percent have it,” said Twahirwa. Part clinic, part laboratory, and part classroom, Boston-based Joslin is a global leader in diabetes research, education, and care, offering the latest advances for treating diabetes and its complications, as well as patient education and support services.
In November, Twahirwa was the organizer of a diabetes forum that put current patients in contact with a panel of experts to address their most pressing questions regarding diabetes.
“We know that in our country, diabetes is also very huge. In 2007, I believe we had approximately 17 million diabetic patients. Now, in 2013, we have more than 23 million,” Twahirwa said at the forum. “Almost every single one of those complications can be prevented if we, the healthcare provider, did our job better and took better care of diabetic patients. But we know it’s not only us. It depends on the patient. That’s why we are here.
“We are here to see if we can help you help us take better care of the community.”
The problem of diabetes is compounded by a region that has more than a quarter of its population (25.3 percent) uninsured, according to NMQF. When you factor in undiagnosed cases and pre-diabetic cases in the Valley, that 11 percent starts to become almost 30 to 40 percent of the population with the disease, which can lead to numerous medical complications, including heart attack, stroke, blindness, nerve damage, and kidney failure, according to Dr. Twahirwa.
Facts regarding diabetes in the region are startling. According to Twahirwa:
- The prevalence of adult diabetes is more than 20 percent higher in South Texas than the entire state of Texas – close to 70,000 people have adult diabetes.
- More than one quarter of all people with diabetes in South Texas have uncontrolled diabetes (25.1 percent, as defined by hemoglobin A1C levels greater than 8).
- A greater percentage of adult diabetics visit the ER or hospital than the national average.
- Individuals in South Texas are uninsured at a rate more than double the national average.
“What we are doing here, in addition to treating diabetes, is focusing on the awareness of this being a pandemic disease affecting Latinos here more than any other part of the country,” Twahirwa said. “It’s challenging, and it’s humbling, because the job is just monumental. When you see that, it’s not only challenging and humbling; it’s also intimidating.”
Can we find a cure?
Certain racial and ethnic groups, including Native Americans and Mexican Americans, are at increased risk for diabetes, obesity, and cardiovascular disease based probably on their genetics, according to Dr. Daniel Hale, current interim director of the Clinical Research Unit at the Regional Academic Health Center (RAHC) in Harlingen.
Hale is the Principal Investigator for the National Children’s Study Center in South Texas. Previously, he received funding for all three of the major NIH diabetes and obesity treatment and prevention initiatives (TODAY, HEALTY, and TrialNet), as well as funding for projects related to childhood diabetes and obesity from the Baptist Health Foundation of San Antonio and the Economic Development Commission in Harlingen.
“A part of it is, you’re dealing with a population that is largely an at-risk population based on their genetics, and they are also a relatively poorer population,” Hale said. “The last time I saw, the poorest county in the country was Hidalgo County. So… there are people who don’t have the resources to allow for change, food at the table, and a roof over their head. They’re not as likely to be worrying about things like healthy food. They are more worried about just eating food and feeding their kids.”
Everyone is at risk for diabetes in the Rio Grande Valley, because residents spend way too much time not being active and way too much interest in large quantities of TV and sedentary activities, Hale said. While rural people, or those who come from a rural background, can afford to eat 4,000 calories a day because they can burn them off, there aren’t that many people around who do that kind of hard labor, he said.
“The medical community is not going to solve this,” Hale said. “It’s going to be communities and families who solve it. When neighborhoods are built with a commitment to having safe places for people to be outside and be active, when we promote a culture of using their own two feet as opposed to an automobile, or when we learn that there are other ways to say ‘I love you’ other than taking someone to McDonald’s and buying them a burger . . . there has to be someone in every family who acts as the agent of change.”
Organizations who represent the poorest residents located in the various colonias say they are mobilizing to make a difference.
In San Juan, members of La Union Pueblo Entero (LUPE), an organization begun in 1989 by Julio Cesar Chavez, are currently working toward creating spaces for colonia residents to be active through their campaign for streetlights and parks. The campaign aims to address the obesity epidemic by changing the conditions that keep colonia residents from leading active lives, according to spokespersons from the organization.
At Proyecto Azteca, an organization that helps colonia residents build safe, decent housing through self-help construction strategies, a concept it calls “sweat equity,” leaders have begun developing a specialized curriculum for residents that combines nutrition with the financial education.
“We are doing financial education, which I really think they should be doing in high school, too, but we had our first one, and we are going to be doing a middle school series of classes,” said Ann Cass, executive director at Proyecto Azteca.
“I had this little brain idea. Let’s combine nutrition with the financial education classes, in other words ‘our body is a bank’,” Cass said. “You have to deposit certain proteins and carbohydrates and fats into it. If we deposit too much of these fats and carbohydrates, it will store and multiply and make us fat. So, we need to figure out how we get healthier food into our “body bank.” I’m going to be writing a curriculum about that and use the same kind of financial education language with the kids.”
Much of the population increase in the Rio Grande Valley can be found in colonias, which are often comprised of substandard housing areas, inadequate roads, drainage, and which frequently do not provide access to safe water or sewer sources. According to a 2006 study by the Texas A&M Health Science Center, the number of colonias in the region is approximately 1,342 with an estimated total population of 300,000.
The study, entitled “Food Environment and Food Choice in Clusters of Colonias in Hidalgo County of the Texas Rio Grande,” finds that almost 70 percent of all colonias in the Valley are located in Hidalgo alone.
Families that reside in areas of persistent poverty face individual, family, and environmental challenges to food security and healthful eating, according to the study. The economic and social burden posed by nutrition-related chronic health conditions like obesity, cardiovascular disease, and diabetes is tremendous.
The burden becomes greater for children and adults who are poor, Hispanic, reside in colonias along the Texas border with Mexico, and face greater vulnerability to food insecurity, poor nutritional health, and adverse health outcomes, the study concludes.
The impact of food deserts
“One thing I am looking at is when you look at the poverty rate, for example, what impact does that have on eating choices, eating options,” asked Dr. Steven Foy, an associate professor and sociologist at the University of Texas-Pan American.
Foy arrived in the Valley in August 2013 from Duke University and specializes in medical sociology, social psychology, as well as race and ethnicity.
“Obviously, Brownsville and McAllen are consistently on top of the list in terms of the highest poverty rates in the nation, and that is creating a lot of different problems. One of them is you get your virtual food deserts,” Foy said, referring to those areas where affordable and healthy food is difficult to obtain, especially for those without proper transportation.
The study by Texas A&M found that the average distance to the nearest supermarket for colonia residents was about 2 to 2.7 miles, the average for this particular Census block group to the nearest supermarket. The distance from a convenience store was about 1.1 miles on average.
Access to high quality food becomes difficult for the poorest residents, and combine that with longstanding transportation issues in the region and increasing food prices, and it puts impoverished communities in a bind, according to Foy.
“In light of our discussion about the Valley and issues of obesity and diabetes, I think a lot of people make acculturation arguments, and there is some research to back this,” Foy said. “If you look at first-generation Latinos in the area, you see that they have a higher rate of eating fruit and vegetables, and lower risk drinking sodas than white citizens. But when you look by the third-generation, you start to see these habits change pretty dramatically, such that you have lower rates of eating fruits and vegetables and higher rates of drinking sodas than whites in the area.”
“You have to take into account the entire health profile, and be careful about not focusing too much on just the outcome of diabetes or just the outcome of obesity,” Foy said.
‘Reaching the BS point’
During the last legislative session, Texas state representative Terry Canales, D-Edinburg, says one of his most bitter battles in Austin was attempting to craft laws that would take energy drinks out of food stamps. His bill HB 523 also prompted Rep. Richard Peña Raymond to introduce HB 751, an attempt to remove buying junk food using government assistance.
“I do not believe that tax dollars should be subsidizing energy drinks. There were over 22,000 hospitalizations related to the consumption of energy drinks, including but not limited to, heart palpitations and caffeine overdoses,” Canales said about the backdrop for creating the bill, which died in committee in 2013. “These are not safe, and they are being purchased with the Lonestar Card. That is a true luxury item. This is an outlier saying ‘we have reached the BS point.’
Canales, who says he has lost family members to diabetes and struggles with his own fluctuating sugar levels despite being fit, says he notices that people who are economically disadvantaged tend to have poorer diets, and there seems to be a direct correlation between the Hispanic and Latino community with diabetes.
“The deeper you delve into the subjects of food stamps, benefits, and how they are interwoven into our society, they are very delicate subjects, and they are very delicate issues that need to be truly and thoroughly vetted,” Canales said. “We have a problem, and we understand that, but we don’t want to try and fix it and create a bigger one. So, I think the safest game plan is to come up with a way to educate people and come up with incentives.”
“It’s innovative projects and programs that Texas needs be adopting. I don’t know if it’s going to work, but we can try it,” Canales said.